Looking at the rural pharmacy workforce


rural Australia

Limitations in the size of the rural and remote pharmacy workforce disadvantages populations in these areas. Research has provided a snapshot of the situation in parts of NSW

This article presents the findings of a recent study that examined the demographics, preceptorship and scope of practice of the workforce in rural NSW pharmacies. Click Pharmacy Workforce Profile to view the full, referenced study. 

AUTHORS: Claire Frewin MPharm, University of Newcastle, Department of Rural Health
Sonja Littlejohns BPharm, University of Newcastle, Department of Rural Health
Tony Smith PhD, University of Newcastle, Department of Rural Health

The size of the Australian rural pharmacy workforce declines relative to the population size as distance from major cities increases.

The Australian Institute of Health and Welfare reports 95.4 full-time equivalent (FTE) pharmacists per 100,000 population in the major cities, compared to 75.2 and 72.3 FTE in inner and outer regional centres respectively, and 56.3 FTE in remote locations.

In 2018/19, the Australian Health Practitioners Regulation Agency (AHPRA) reported 31,955 registered pharmacists in Australia, of whom about 77% practice in major cities, while 6.7% serve outer regional communities, and 1.2% work in remote or very remote locations.

The role of pharmacists continues to evolve in Australia, as well as in other developed countries. Changes have been towards more patient-centred practice models, such as medication management and review.

While broadening of the scope of practice of pharmacists is a positive development, it presents challenges for the regional, rural and remote practitioners when there is a workforce undersupply.

Expectations that pharmacists perform a wider range of duties places demands on the practitioners in terms of time and availability. It also creates the need for accredited and continuing professional development (CPD), which can be difficult to access outside metropolitan areas because of costs of registration and travel, as well as time way from family and the community that the pharmacists serve.

This is exacerbated in small communities where the local pharmacist is a sole practitioner.

Under successive Community Pharmacy Agreements, the Australian government has funded Rural Pharmacy Workforce Programs, including the Rural Pharmacy Liaison Officer (RPLO) Program.

The RPLOs are pharmacists employed in a clinical-academic capacity to support pharmacy students on placements outside major cities. Embedded in university departments of rural health, the RPLO role is funded under the Rural Health Multidisciplinary Training (RHMT) Program and the Seventh Community Pharmacy Agreement (7CPA). RPLOs also support local rural pharmacists to access CPD.

The University of Newcastle (UON) employs two part-time RPLOs, one in Tamworth, in the New England and Northwest region of New South Wales, and another in Taree, in the Lower Mid-North Coast region.

To better inform support for rural students and pharmacists, there was a perceived need to survey the rural pharmacists in those regions.

The Taree and Tamworth workforces

A total of 50 pharmacists provided data, representing about 25% of the registered pharmacy workforce in the combined regions. There were 28 respondents from the Taree region and 22 from the Tamworth region (see Table 1 for demographic details).

Only one respondent was a hospital pharmacist, the rest being employed in community pharmacy, including one intern. The majority (62%) were female. Almost half indicated that they were employed as community pharmacists and 22 (44%) were pharmacy owners or owner-managers.

Distribution of age was similar to the 2018/19 AHPRA workforce age profile, with the largest proportion in the 25 to 34 age category, the next largest category being 35 to 44 years. The smallest age category was less than 25 years (n = 2) and only one respondent was older than 70 years.

Nine respondents (18%) thought they may retire in the next five years, with a further five (10%) unsure.
Under the Modified Monash Model (MMM) classification, no locations fell into the two lowest, most accessible, or two highest, most remote, categories. Ten locations were classified as MMM3 (n = 35 respondents) and six as MMM5 (n = 6).

Table 1: Respondents demographic variables (n=50) 

Variable

n

%

Professional Roles

Accredited Pharmacist

2

4

Community Pharmacist

24

48

Hospital Pharmacist

1

2

Managing Pharmacist

4

8

Owner

1

2

Owner Manager

17

34

Intern Pharmacist

1

2

Cohort (data collection hub)

Coastal (Taree)

28

56

Inland (Tamworth)

22

44

Gender

Female

31

62

Male

19

38

Pharmacy work in the region

Respondents estimated their average hours worked each week. With two missing, responses were negatively skewed, a quarter of respondents working 30 or less hours per week. With a mean of 35.4 hours and median of 40.0 hours, 67% of the respondents worked 36 or more hours per week.

Though almost twice as many female as male respondents worked less than 20 hours per week, there was no difference in the means. The average weekly hours reported by owner-manager pharmacists was 33.9 hours, compared to 37.5 hours for other community pharmacists.

Some 48% of respondents perceived a need to increase the number of pharmacists where they worked, but only 4% wanted to increase pharmacists’ hours.

Of the 22 owner-managers, eight (36%) said they would employ overseas trained pharmacists and two were ‘unsure’, while 12 (55%) did not respond.

While 27 respondents (54%) indicated that their role included supervision of students on placement, 64% indicated that the site where they work provided placement opportunities.

Of the 23 respondents that did not perform student supervision, five said they would be interested in doing so and that there was potential for student placements where they worked. Providing student placements was associated with more accessible locations, although four of the six respondents in MMM5 locations regarded their workplace as a potential student placement site.

The same association was not found for intern supervision, however. Excluding the intern, 23 of the respondents (47%) indicated that they had a role in intern supervision (n = 12) or would be interested in such a role (n = 11). Meanwhile, 26 respondents (53%) indicated that their workplace either currently (n = 22) or could potentially (n = 4) supervise interns.

Types of services provided are shown in Table 2. Six service types were provided by 80% or more of the respondents, either by the pharmacist or another trained staff member, or by an external provider.
If no response was given, it was assumed the service was not offered and for two service types, Chronic Obstructive Pulmonary Disease (COPD) screening and International Normalised Ratio (INR) monitoring; more than 80% did not respond.

Asked whether, given adequate staffing, they would broaden the range of services or scope of practice, only three respondents (6%) said ‘No’, 74% ‘Yes’ and 20% were ‘Unsure’.

Also asked what activities, if any, were limited by ‘staffing issues’, the most common responses were ‘limitations on providing professional services’ (58%) and in ‘extending scope of practice’ (56%).

Limiting ‘capacity to take annual leave’ was indicated by 52%, while the least common was limiting ‘supervision of students and interns’ (24%). ‘Attending CPD events’ and ‘attracting locums’ were both flagged by 30%.

Table 2: Responses to the question of what services were provided from the list below, either by staff within or external to the pharmacy. If neither, no response was recorded.

Professional

Service Offered

Delivered by Pharmacist or Pharmacy Staff

Delivered by

External Providers

Did Not Respond

Opioid substitution program

18 (36%)

3 (6%)

29 (58%)

Diabetes educator clinics

18 (36%)

4 (8%)

28 (56%)

Sleep apnoea

12 (24%)

3 (6%)

35 (70%)

Needle syringe program

28 (56%)

3 (6%)

19 (38%)

Staged supply

39 (78%)

1 (2%)

10 (20%)

Smoking cessation advice and support

21 (42%)

2 (4%)

27 (54%)

Weight loss programs

33 (66%)

1 (2%)

16 (32%)

Immunisation

41 (82%)

0

9 (18%)

Meds Checks / Diabetes Checks

46 (92%)

0

4 (8%)

Dose Administration Aids

26 (52%)

3 (6%)

21 (42%)

COPD screening

    3 (6%)

2 (4%)

45 (90%)

Compounding

31 (62%)

5 (10%)

14 (28%)

Clinical interventions

47 (94%)

0

3 (6%)

INR monitoring

    1 (2%)

6 (12%)

43 (86%)

HMR/RMMR

22 (44%)

20 (40%)

8 (16%)

Blood cholesterol monitoring

15 (30%)

3 (6%)

32 (64%)

Blood glucose monitoring

33 (66%)

1 (2%)

16 (32%)

Blood pressure monitoring

47 (94%)

0

3 (6%)

A snapshot of non-metropolitan pharmacy

The regions in this project are different and diverse, encompassing both inland and coastal regional, rural and remote communities. They are broadly reflective of other parts of non-metropolitan Australia, and the demography of the pharmacy workforce bears similarities to the national 2018/19 AHPRA workforce data.

More than 60% of the survey respondents were in the prime working years of 25 and 45. Previous studies had suggested an aged rural pharmacy workforce in similar regions.

The results suggest a stable core of practising, mostly female (> 60%) pharmacists, with fewer than 20% considering retirement within five years.

The average hours worked per week and distributions of hours worked by males and females were similar to previous studies and, in this study, the mean hours worked by females was no different to males. This seems contrary to the perception that feminisation of the pharmacist workforce leads to a decrease in workforce participation rates.

While a greater proportion of females worked less than 20 hours per week, a higher proportion of males worked between 20 and 34 hours per week, less than full-time equivalent.

As one respondent commented, attracting young pharmacists to rural areas is difficult. Nearly half the respondents considered that they needed more pharmacists.

Efforts to build the rural pharmacy workforce are ongoing. The number of pharmacy schools in Australia has more than doubled in the past 15 years, with some established in regional locations, and graduate numbers are at unprecedented levels.

Increased student and intern numbers promises long-term benefits, with the hope that a ‘trickle-down effect’ will lead to more graduates entering rural practice in the future. However, passive trickle-down theory, with overflow of practitioners into rural practice, has been questioned and largely refuted as an effective solution to the rural medical workforce shortage.

Rather, there is a need for affirmative action. Students and early career practitioners must experience rural practice and lifestyle, the challenge being to get them into regional, rural and remote areas for part of their education and training.

There was evidence in this project of some under-utilisation of rural student placements and internship opportunities. Pharmacists willing to provide student and intern preceptorship exceeded the number with an active preceptor role. There is a need for further investigation and if similar under-utilisation occurs in other regional, rural and remote regions, it may be argued that more work is required to increase student and intern exposure to rural practice.

While predictors of rural practice include rural origin and attending a rural university, compared to rural curriculum alone, a positive placement experience is strongly associated with rural practice intentions.
The RPLOs are well placed to support the rural career pipeline, from student placements through internship and into early-career and ongoing professional practice.

Comments from pharmacists

Six respondents (14%) gave open-ended comments, most about staffing and recruitment, such as:
“When pharmacist in charge, I am a sole pharmacist on duty and struggle to find enough hours to complete necessary tasks. Would love to have another pharmacist on duty to enhance clinical role.” (Respondent #4, MMM3)

“It is difficult in rural areas to balance cost with adequate staffing, particularly due to decreased income in recent years (codeine rescheduling, accelerated price disclosure) …” (Respondent #37, MMM5)

One respondent expressed a desire to do more:
“I enjoy being a pharmacist and want to learn and offer more knowledge and services to consumers, time permitting.” (Respondent #7, Location unknown)

Motivations for rural practice

One of the motivators for rural practice is the potential for expanded scope of practice and job satisfaction is associated with the ‘use of advanced skills’. Though opposed by some in the medical profession, and often poorly understood, provision of an extended range of primary health care services by pharmacists may be beneficial in rural communities.

More could be done in roles such as COPD screening, and INR and cholesterol monitoring. Given the comparatively high prevalence of cardio-vascular disease risk factors in rural communities, pharmacist-led interventions in managing hypertension and hyperlipidaemia could improve pharmacological treatment.

Almost three-quarters of respondents indicated that staffing issues limited extending their scope of practice.

Increasing demands in a climate of workforce undersupply can lead to career frustration and decreasing job satisfaction, so addressing workforce under supply, in parallel with pharmacist role development, is essential.

Conclusions

Over the past 10 to 15 years, changes have been debated and implemented in both pharmacy education and practice. There is a need to monitor such changes, how they are implemented and the outcomes produced.

Large scale, national, profession-wide data collection is essential to provide a macro-perspective, while projects such as that reported in this article give insight at the meso-scale, community level and the micro-level of individual practitioners.

There is a need for further localised studies of the regional, rural and remote pharmacy workforce (as well as other health professions) to better understand local variation in work patterns and the needs of practitioners and to inform support and future development.

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